Programming to reduce stunting

Stunting leads to irreversible negative problems in cognitive ability and an increased risk of chronic diseases in adult life. Social costs are also large. The reduced cognitive ability leads to poor learning and consequently reduced productivity and lower adult wages. High levels of stunting are likely contributors to negative youth development.

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Stunting is caused by poor nutrition and repeated childhood illnesses, and it is a problem in many countries. It is often a persistent problem and difficult to reverse, but reducing the rate is possible. It requires systemic change: a thousand small changes.

Based on solid academic research, USAID's learning from implementation of projects in various countries, and the application of global best practices, projects which are properly designed and led can be the key coordinator in catalyzing many of the needed changes.

The key element of the strategy is to focus on the true causes of stunting rather than the somewhat 'down stream' causes commonly cited such as poverty, subsistence farming, poor access to health clinics, and so on. These are proximate not core causes.

The core causes of stunting have been identified:

"Nepal has arguably achieved the fastest recorded decline in child stunting in the world" from 57.5% in 2001 to 40.5% in 2011 with "asset accumulation, health & nutrition interventions, maternal educational gains, and improvements in sanitation (as) the drivers of change" (Global Nutrition Report 2016 from the International Food Policy Research Institute's Poverty, Health, and Nutrition Division).

Another IFPRI paper, "How did Bangladesh Reduce Stunting so Rapidly?", attempted to quantify the influence of factors associated with reduced stunting and found the sources of change in stunting for CU5 were attributable 22% to asset ownership, 15% maternal education, 12% open defecation, 11% paternal education, 10% maternal height, 10% ANC visits, 8% born in a medical facility, 8% birth order, and 4% birth interval. This is based on DHS-type surveys in 3-4 year intervals from 1997 to 2011 and presented in the 2014 Global Nutrition Report.

These numbers might strike a reader as somewhat dubiously exact, but few would doubt that the education levels of the mother and the father are instrumental: good general knowledge fosters a receptivity to objective information, and even modest specific knowledge provides an understanding of basic science and health. The researchers' attribution to parental education of 26% of the total cause of stunting is reasonable.

Assets, too, in second place, are a reasonable indicator. Higher asset levels imply a higher sense of financial security, and thus when cash is short a family is less likely to skimp on food.

The presence of open defecation is a recurring topic in general literature on this subject and an issue in many places, but another source is important as well. Environmental enteropathy (proximity to animal fecal matter) is common in rural and semi-urban households and is likely a factor in many countries' stunting numbers.

It is somewhat surprising, perhaps, that whether the child was born in a hospital or not comes in at only 8%, but unpacking the data indicates that it is not so much the facility or its condition as it is the staff that influences a child's nutrition. The health care workers' guidance and instructions are critical in starting breast feeding early, and early breast feeding is strongly correlated to exclusive and to more frequent breast feeding through the next six months.

This research has specific implications for effective programming.

The causes of stunting identified by research are at the household or individual level so interventions must be aimed at people-- at mothers and fathers rather than at communities.

The persistence of high stunting numbers shows that broad messaging does not move the number. Community-wide messaging and mass media are not very useful in this regard.

This means the messaging for, say, IYFC should bring together activities around early & exclusive breastfeeding, complementary feeding, and infant feeding into a cohesive package about having a healthy baby. Frankly, too many programs 'implement activities'-- that is, a typical EBF event tends to be about a certain practice or technique and somewhat isolated from its meaning to a parent.

Similar to a certain extent, the very common handwashing lessons too often have a 'behavior-centric' feel to them. The programs certainly emphasize the risk of illness from unclean hands, but I have not seen a message about stunting included. In this case, 'targeting people' means an end to handwashing classes in favor of discussion of open defecation and environmental enteropathy as threats to your child's health and development. Parents will understand this.

With resources limited in the most health cares system, we must ensure that care reaches the households in need.

Resources must reach the households where signs of poor nutrition and childhood illness are found. To bring the message and support directly to where it is needed, direct delivery is needed.

Community health workers visiting target households contribute to better results as "nutrition education improves caregiver IYCF practices through ... provision of information about local foods, processed complementary foods, in-home fortification of foods to caregivers, and promotion of appropriate feeding behaviors" (Guiding Principles for Complementary Feeding of the Breastfed Child, PAHO/WHO 2003).

"Lay counselors are shown to be most effective in increasing the initiation and duration of exclusive breastfeeding." Unfiltered and accurate advice is needed to reinforce the messages from the health care workers in the district hospitals. (Fairbank L, O‘Meara S, Renfrew MJ, Woolridge M, Snowden AJ, Lister-Sharp D. "A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding", Health Technology Assessment 2000).

This directly addresses two identified causes of stunting: few ANC visits and babies born outside of health care facilities.

"In addition to providing good quality care at facilities, it is imperative that health programs cover women and newborns at home to promote healthy behaviors, including preventive care, identifying problems and danger signs, and seeking appropriate care. Community health workers/volunteers can play a very important role in identifying and interacting with women of reproductive age and their families, with community and religious leaders, and with health care providers at the facility level to achieve better results for pregnant women and newborns." (Basic Support for Institutionalizing Child Survival and the Prevention of Postpartum Hemorrhage Initiative, 2009. Training Community Health Workers to Give Maternal and Newborn Health Messages: A Guide for Trainers.

The CHWs are not tasked with provision of clinical care but rather have an extensive role in health promotion and supportive care that focuses on specific MCHN issues. They refer cases to local health care professionals and facilitate home visits of clinic staff.

This is "level one" of CHWs world wide, the "Intermittent and Ongoing Community Health Volunteers" as described in the Bureau for Global Health's Maternal and Child Health Integrated Program (MCHIP, implemented by the Jhpiego Corporation). The CHWs are not auxiliary health workers or health extension workers. Their job description is focused only on key topics, there is little or no special equipment needed, training will be done in the communities not in medical schools and preferably by the staff of the local PHC, and there is no formal certification.

Effective training will emphasize the development of specific competencies and skills, usually:

Increasing care seeking, ANC visits, and hospital delivery
IYCF in general and in difficult circumstances such as HIV and in emergencies
Identifying danger signs during pregnancy
Teaching early and exclusive breastfeeding and proper positioning
Teaching mother's care of the low birth weight baby
Recognizing the signs of stunting and underweight
Recognizing signs of under nourished teen aged girls

In promoting this, we must recognize that facility and district health managers will need orientation to the new CHW approach and why it will be effective in the management of MCHN challenges in their areas. Facilty staff and leadership will also need be motivated to support the new program, part of which requires providing appropriate time allocations to fulfill their managerial and supervisory responsibilities.

We must understanding the political landscape-- often resistant to change-- and manage and monitor it assiduously. It is often useful to present the growing evidence that well designed community based programs using well trained community health workers can be effective, evidence the USAID Bureau for Global Health has gathered.

Holistic programming is a MCHN best practice.

Ensuring proper nutrition requires a multi-sectoral solution, and improving MCHN is a complicated affair. Programs need many parts, and the best programs integrate these in integrated activity sets. A write up of a Bangladesh program gets into this here.

Notably, this must include economic development programming. Inadequate asset accumulation is an identified cause of stunting, and programming should be aimed at building the financial well-being of poor households-- promotion of regular saving, micro-franchised ag input suppliers, market aggregators, and so on should be joined to MCHN programs.

Decision making is key to progress, and this means life skills workshops are indepensible.

This includes topics such as women as decision makers, social networks and safety nets, health & wellness, building family assets, and similar.

For younger women issues such as intra-household food distribution are important, for women it might include conflict mediation or consensus building, for men it might include gender roles, and for older women it might include traditional roles and gender.

This is the key point in transformative learning, a process which over a few months enables a person to look at herself, her resources, and life around her in a different way and thus make different decisions as circumstances change.

Transformative learning is absolutely critical to the decision making that turns our outcomes into results.

Local solutions are effective.

Improving sanitation, another specific cause of stunting, can be a massive task, and in many countries private sector engagement has achieved very good results in reducing open defecation in communities.

Improved latrines using local materials in low cost construction is an excellent small business. Projects can train masons, use behavior change communication as promotion and advertising, and replicate the small business model over and over.

Mobilization of community resources is another proven approach to improving community sanitation. Development projects can foster a structured planning process in which the community analyzes its needs and resources and establishes its priorities. To kick-start implementation, the project can make a very small grant for the first activity to validate the process and simultaneously solve the most pressing sanitation issue in the community.

Another example is a community health care financing model dedicated to medical needs such as emergency transportation. Basically, a modest informal savings bank is created to provide for urgent care. It is a beautifully simple solution to an urgent problem. Successful in many countries, it should be replicated widely.

We need to try more difficult things, be more ambitious, more bold.

Community campaigns to promote dietary diversity don't cut it. To address the multi-sector problem of improving nutrition and health a range of coordinated efforts are needed: greater private sector engagement for sustainability, community water management, NGO capacity building, and more. You know this.

We also know funds are always limited so development projects must sieze opportunities to use their resources to launch demonstration programs in big numbers, apply global best practices to demonstrate their viability and effectiveness in the local context, and then show the ministries how to roll out the successful models.

We should have a mission to push adoption of interventions proven effective worldwide. Take ideas to high levels and push for flexibility and a receptivity to new approaches. That is, while we support, say, broader vitamin A use, we should also intentionally push for a change in approach by the ministries as another objective. We should go for both.